1. Field of the Invention
This invention relates to compositions that may be used as pharmaceutical compositions, methods and kits, more particularly to improved pharmaceutical compositions, methods and kits including paclitaxel and pharmaceutically-acceptable, water-miscible, non-aqueous solvents.
2. Description of Related Art
Paclitaxel is a unique diterpene anticancer compound derived from the bark of the Taxus brevifolia (Pacific yew) tree. A crude extract of the bark demonstrated antineoplastic activity in preclinical tumor screening 30 years ago as part of the National Cancer Institute's (NCI's) large-scale screening program. The active component of the extract, paclitaxel, was isolated and described by M. C. Wani et al, Plant antitumor agents. VI: The isolation and structure of Paclitaxel, a novel antileukemic and antitumor agent from Taxus brevifolia, J. Am. Chem. Soc. 93:2325-2327 (1971). This document, and all others referred to herein, are incorporated by reference as if reproduced fully below.
In 1979, Schiff and coworkers rekindled interest in the development of paclitaxel by demonstrating its novel mechanism of action. Paclitaxel stabilizes the tubulin polymer and promotes microtubule assembly, rather than inducing microtubule disassembly like the antimicrotubule agents colchicine, vincristine, and vinblastine. This stabilization results in the inhibition of the normal dynamic reorganization of the microtubule network. Encouraging response rates (complete and partial) have been reported in single-agent phase II studies of paclitaxel in breast cancer, previously untreated non-small-cell lung cancer, head and neck cancer, and refractory ovarian cancer.
Unfortunately, paclitaxel is poorly soluble in water (less than 0.01 mg/mL) and other common vehicles used for the parenteral administration of drugs. Certain organic solvents, however, may at least partially dissolve paclitaxel. However, when a water-miscible organic solvent containing paclitaxel at near its saturation solubility is diluted with water, the drug may precipitate.
Solubilization of compounds with surfactants allows for dilution of saturated or near-saturated formulations. Consequently, researchers formulated paclitaxel formulations using 50% Cremophor EL/50% dehydrated alcohol, USP, diluted in NS or D5W to a final concentration of 5% Cremophor EL/5% dehydrated alcohol or less, for the intravenous administration of drug to humans in initial clinical trials. (Cremophor EL; Badische Anilin and Soda Fabrik AG [BASF], Ludwigshafen, Federal Republic of Germany). Paclitaxel for injection concentrate is currently available from Bristol-Myers Squibb Co. (New York, N.Y.) in 30-mg (5-mL) single-dose vials. Each milliliter of formulation contains approximately 6 mg Paclitaxel, 527 mg of Cremophor EL, and 49.7% (vol/vol) dehydrated alcohol. This concentrated formulation must be further diluted with NS, D5W, D5NS, or D5W-R prior to administration. Additional information regarding Cremophor formulations of paclitaxel may be found in Agharkar et al., U.S. Pat. No. 5,504,102.
An unexpectedly high incidence of serious hypersensitivity reactions was noted in phase I studies of the paclitaxel/Cremophor formulations. At least one patient's death was caused by an allergic reaction induced by the formulation. It is not clear whether the hypersensitivity reactions were related to the Cremophor EL vehicle or to the paclitaxel. D. M. Essayan et al., Successful Parenteral Desensitization to Paclitaxel, J. Allergy and Clin. Immun. 97:42-46 (1996). Studies have shown that the Cremophor EL vehicle induces histamine release and hypotension in dogs within 10 minutes of administration.
In January 1985, the NCI sent a letter to all phase I investigators using paclitaxel, directing them to increase the duration of paclitaxel infusions and to pretreat all subjects with antihistamines (both H, and H2 blockers) and steroids. The incidence of hypersensitivity reactions subsequently decreased. Because the infusion duration was increased and pretreatment medications were added at the same time, it was not possible to determine whether infusion rate or pretreatment was the important factor.
Further studies were carried out in which paclitaxel was administered after premedication with steroids (such as dexamethasone), antihistamines (such as diphenhydramine), and H2-antagonists (such as cimetidine or ranitidine), and the infusion time was extended to 24 hours in an attempt to eliminate the most serious allergic reactions. See Einzig, et al., Phase II Trial of Taxol in Patients with Metastatic Renal Cell Carcinoma, Cancer Investigation, 9:133-136 (1991); A. B. Miller et al., Reporting Results of Cancer Treatment, Cancer 47:207-214 (1981). Additional description of premedication techniques may be found in Carretta et al., U.S. Pat. No. 5,670,537.
Although use of a long infusion duration seems to reduce the occurrence of hypersensitivity reactions, the long infusion duration is inconvenient for patients, and is expensive due to the need to monitor the patients for the entire 6 to 24-hour infusion duration; further, the long infusion duration requires that patients spend at least one night in a hospital or treatment clinic. The desire to reduce the cost and inconvenience led to shortened infusion regimes. Such shortened infusions are described in Carretta et al., U.S. Pat. No. 5,641,803.
However, these shortened infusion regimes still require the use of pretreatment, which is expensive and taxing for the patient. Additionally, even for shortened infusion times, paclitaxel is still administered in a Cremophor-containing formulation that is believed by many clinicians to promote hypersensitivity reactions in certain patients despite pretreatment.
There are other disadvantages to using Cremophor formulations as well. Polyvinylchloride (PVC) infusion bags and intravenous administration sets usually contain diethylhexylphthalate (DEHP) as a plasticizer to maximize component flexibility. DEHP leaches to some extent into aqueous infusion fluids and blood products that come in contact with PVC materials. Exposure of animals to chronic high doses (more than 100 mg/kg) of DEHP has resulted in toxic effects including growth retardation, liver weight increase, liver damage, testicular atrophy, teratogenicity, and carcinogenicity. Cosolvents and surfactants may increase the amount of plasticizer leached. Waugh and colleagues evaluated the quantities of DEHP extracted from PVC infusion devices by the commercially available paclitaxel formulation. Substantial quantities of DEHP were extracted by all formulation concentrations tested. Therefore, there is a substantial health risk to patients receiving paclitaxel in the commercially available formulation using conventional PVC-containing equipment. While the danger can be ameliorated by using different materials for the equipment, this is not a complete solution.
There is therefore a need for improved formulations comprising paclitaxel, methods of treatment using these formulation and kits comprising these formulations, to overcome the problems of conventional paclitaxel formulations as noted above and as known to one of skill in the art.